PATIENT PROFILE FORM
PATIENT NAME: ABC HOSP. NO: 02191888
AGE: 35yr WEIGHT: 95kg HEIGHT: 6'2'' SEX: M/F : M
DATE OF ADMISSION:17/08/11
DATE OF DISCHARGE: 21/08/11
COMPLAINTS ON ADMISSION: cold, occasional mild headaches and some dizziness after he takes his morning medications.
HPI: He states that he is dissatisfied with being placed on a low sodium diet by his former primary care physician. His BP 2 months ago was 140/90 mm Hg. He reports a “usual” chronic cough and shortness of breath, particularly when walking moderate distances
MEDICAL HISTORY: Type 1 diabetes mellitus; Chronic obstructive pulmonary disease Stage 2 (Moderate); Chronic kidney disease
MEDICATION HISTORY: Insulin 70/30, 24 units Q AM, 12 units Q PM; Albuterol INH 2 puffs Q 4–6 h PRN shortness of breath; Tiotropium DPI 18 mcg 1 capsule INH daily; Salmeterol DPI 1 INH BID; Entex PSE 1 capsule Q 12 h PRN cough and cold symptoms; Acetaminophen 325 mg po Q 6 h PRN headache
SOCIAL HISTORY: Former smoker (smoked 1 ppd × 28 years); reports moderate amount of alcohol intake. He admits he has been non adherent to his low sodium diet. He does not restrict his diet in any way. He does not exercise regularly and is limited somewhat functionally by his COPD.
FAMILY HISTORY: - Father died of acute MI at age 71. Mother had both HTN and DM.
PREVIOUS ALLERGIES: -
PHYSICAL EXAMINATION: Patient is a well-developed, well-nourished moderately overweight
GENERAL - P-I-C- C- L- E+
VITAL SIGNS -BP 150/92 mm Hg (sitting; repeat 159/90), HR 76 bpm (regular), RR 16 per min, T 37°C
HEENT - TMs clear; mild sinus drainage; mild arterial narrowing and arteriovenous nicking, with no exudates or hemorrhages
CVS - S1 S2 heard; No S3 or S4
RS - Few basilar crackles, mild expiratory wheezing
GIT - No splenomegaly/ hepatomegaly
GU - NAD
EXT - NAD
CNS - NAD
PROVISIONAL DIAGNOSIS: HTN ? MI ? CHF?
ROUTINE BIOCHEMICAL INVESTIGATIONS (18/8/11)
HAEMATOLOGY:
Na 142 mEq/L
K 4.8 mEq/L
Cl 102 mEq/L
CO2 27 mEq/L
BUN 22 mg/dL
SCr 1.6 mg/dL
Glu 136 mg/dL
Mg 2.3 mEq/L
Ca 9.7 mg/dL
T Bili: 1.5 mg/dL
D Bili: 0.7 mg/
T. Prot: 6.0 g/dL
HbA1C 6.2%
Alb: 3.5 g/dL
Glob: 3.1 g/dL
AST: 76 IU/L
ALT: 69 IU/L
T.ch 196 mg/dL
LDL 141 mg/dl
HDL 32mg/dl
TG 170 mg/dl
RBC 3.8 × 106/mm3
WBC 9.0 × 103/mm3
N: 67%(35-75) Hgb 13 g/dL
L: 16% (20-45) Hct 40%
M:12%(0-10) MCV
E: 8(0-5) MCH:
B: 3(0-2) MCHC
Plt 189 × 103/mm3
ESR: 20 (0-20mm/hr)
URINE ANALYSIS
OTHERS
ECG: Normal sinus rhythm
ECHO (6 months ago) : Mild LVH, estimated EF 55 %.
Spirometry (6 months ago): FVC 2.38 L (54% pred); FEV1 1.21 L (38% pred); FEV1 1.21 L (38% pred)
FINAL DIAGNOSIS: Hypertension, uncontrolled ;Type 1 diabetes mellitus, controlled on current insulin regimen; Moderate COPD
DAY
INVESTIGATION
D1
Afebrile, PR: 82bpm, BP: 152/90, PR: 80 bpm , headache, cold
D2
PR: 88 bpm; BP: 152/90, headache, dizziness. Cold reduced
D3
Temp:38 ,BP: 150/90,PR: 80 bpm, headache, dizziness, cold reduced
D4
Temp:37, BP: 150/90, PR: 86 bpm, persistent symptoms, discharge against medical advice
DRUG TREATMENT CHART:
DRUG WITH DOSE & ROUTE
START DATE
STOP DATE
COST
INDICATION AND JUSTIFICATION
GENERIC NAME
BRAND
NAME
Answers
Explanation:
PATIENT PROFILE FORM
PATIENT NAME: ABC HOSP. NO: 02191888
AGE: 35yr WEIGHT: 95kg HEIGHT: 6'2'' SEX: M/F : M
DATE OF ADMISSION:17/08/11
DATE OF DISCHARGE: 21/08/11
COMPLAINTS ON ADMISSION: cold, occasional mild headaches and some dizziness after he takes his morning medications.
HPI: He states that he is dissatisfied with being placed on a low sodium diet by his former primary care physician. His BP 2 months ago was 140/90 mm Hg. He reports a “usual” chronic cough and shortness of breath, particularly when walking moderate distances
MEDICAL HISTORY: Type 1 diabetes mellitus; Chronic obstructive pulmonary disease Stage 2 (Moderate); Chronic kidney disease
MEDICATION HISTORY: Insulin 70/30, 24 units Q AM, 12 units Q PM; Albuterol INH 2 puffs Q 4–6 h PRN shortness of breath; Tiotropium DPI 18 mcg 1 capsule INH daily; Salmeterol DPI 1 INH BID; Entex PSE 1 capsule Q 12 h PRN cough and cold symptoms; Acetaminophen 325 mg po Q 6 h PRN headache
SOCIAL HISTORY: Former smoker (smoked 1 ppd × 28 years); reports moderate amount of alcohol intake. He admits he has been non adherent to his low sodium diet. He does not restrict his diet in any way. He does not exercise regularly and is limited somewhat functionally by his COPD.
FAMILY HISTORY: - Father died of acute MI at age 71. Mother had both HTN and DM.
PREVIOUS ALLERGIES: -
PHYSICAL EXAMINATION: Patient is a well-developed, well-nourished moderately overweight
GENERAL - P-I-C- C- L- E+
VITAL SIGNS -BP 150/92 mm Hg (sitting; repeat 159/90), HR 76 bpm (regular), RR 16 per min, T 37°C
HEENT - TMs clear; mild sinus drainage; mild arterial narrowing and arteriovenous nicking, with no exudates or hemorrhages
CVS - S1 S2 heard; No S3 or S4
RS - Few basilar crackles, mild expiratory wheezing
GIT - No splenomegaly/ hepatomegaly
GU - NAD
EXT - NAD
CNS - NAD
PROVISIONAL DIAGNOSIS: HTN ? MI ? CHF?
ROUTINE BIOCHEMICAL INVESTIGATIONS (18/8/11)
HAEMATOLOGY:
Na 142 mEq/L
K 4.8 mEq/L
Cl 102 mEq/L
CO2 27 mEq/L
BUN 22 mg/dL
SCr 1.6 mg/dL
Glu 136 mg/dL
Mg 2.3 mEq/L
Ca 9.7 mg/dL
T Bili: 1.5 mg/dL
D Bili: 0.7 mg/
T. Prot: 6.0 g/dL
HbA1C 6.2%
Alb: 3.5 g/dL
Glob: 3.1 g/dL
AST: 76 IU/L
ALT: 69 IU/L
T.ch 196 mg/dL
LDL 141 mg/dl
HDL 32mg/dl
TG 170 mg/dl
RBC 3.8 × 106/mm3
WBC 9.0 × 103/mm3
N: 67%(35-75) Hgb 13 g/dL
L: 16% (20-45) Hct 40%
M:12%(0-10) MCV
E: 8(0-5) MCH:
B: 3(0-2) MCHC
Plt 189 × 103/mm3
ESR: 20 (0-20mm/hr)
URINE ANALYSIS
OTHERS
ECG: Normal sinus rhythm
ECHO (6 months ago) : Mild LVH, estimated EF 55 %.
Spirometry (6 months ago): FVC 2.38 L (54% pred); FEV1 1.21 L (38% pred); FEV1 1.21 L (38% pred)
FINAL DIAGNOSIS: Hypertension, uncontrolled ;Type 1 diabetes mellitus, controlled on current insulin regimen; Moderate COPD
DAY
INVESTIGATION
D1
Afebrile, PR: 82bpm, BP: 152/90, PR: 80 bpm , headache, cold
D2
PR: 88 bpm; BP: 152/90, headache, dizziness. Cold reduced
D3
Temp:38 ,BP: 150/90,PR: 80 bpm, headache, dizziness, cold reduced
D4
Temp:37, BP: 150/90, PR: 86 bpm, persistent symptoms, discharge against medical advice
DRUG TREATMENT CHART:
DRUG WITH DOSE & ROUTE
START DATE
STOP DATE
COST
INDICATION AND JUSTIFICATION
GENERIC NAME
BRAND
NAME
Answer:
What do we have to doooooooooooooo
Explanation:
No queston only answers